Patient Name:
Previous Dysport Injections:
Number of Treatments:
Regions:
Response:
Pre-existing facial palsy/weakness:
Aminoglycosides
Antibiotics
Facial Palsy
Allergy to Human Albumen
Pregnancy & Lactation
I, the above and undersigned, have requested that Doctor treat my facial expression lines with Dysport. This is the trademark for Dysport as produced by Merz.
As the results vary, I have been informed that the practice of medicine is not an exact science and that no guarantees can or have been made concerning expected results in my case. I understand that several sessions may be necessary to complete the injection series.
I am aware that when small amounts of purified Dysport are injected into a muscle it causes weakness or paralysis of that muscle.
I understand that the muscles injected will not function whilst the injection is effective, (e.g., I will not be able to frown if the muscles involved in frowning are injected), and this will reverse itself after a period of months at which time re treatment is appropriate.
Dysport takes approximately four (4) – seven (7) days to take/show effect and the results generally ‘peak’ at 30 days. The effects of Dysport generally last four (4) months but can last longer or shorter in some patients.
Dysport treatment of frown lines can cause minor temporary drop of an eyebrow in 2% of injections. In the unlikely event this occurs please feel free to talk with your doctor.
Occasionally, slight swelling or bruising can occur and if so, can last for three (3) to seven (7) days.
I am not aware that I am pregnant, and I do not have any significant neurological disease.
Eyelid Ptosis
Minor Bruising
Transient Headache
Double Vision
Brow Ptosis
Failure of Response
I have read the above and understand it.
I certify that I have had sufficient opportunity for discussion and to ask questions.
I hereby consent to the treatment as outlined.
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